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Review of Physical Exam and An Approach To The

David G. Liddle, MD Assistant Professor of Orthopedics Assistant Professor of Internal Medicine Vanderbilt University Medical Center Nashville, TN

Vanderbilt Disclosures • No financial disclosures or conflicts of interest

Vanderbilt Sports Medicine Objectives

• Review pertinent and pathology associated with common causes of shoulder pain • Review historical and physical exam findings that help differentiate common causes of shoulder pain • Review imaging findings relevant to these causes of pain and discuss a rationale for appropriate use of diagnostic tests • Review the best evidence available to the guide treatment of these conditions

Vanderbilt Sports Medicine Vanderbilt Sports Medicine Syst. Reviews of RCT

Level I – Randomized Controlled Trials

Observational studies Level II – Prospective Cohort Level III – Case-Control or Retrospective Cohort

Level IV – Case studies

Level V – Anecdote and personal opinions

Vanderbilt Sports Medicine Anatomy Review

http://www.aafp.org/afp/2004/1115/p1947.html http://www.bandhayoga.com/images/Blog/blog2 Vanderbilt Sports Medicine 3_serratus_anatomy.jpg XR Review AP Int. & Ext. Rotation & Axillary views +/- Scapular-Y view

Vanderbilt Sports Medicine Non- Shoulder Pain

Non-Operative Operative &/or Non-Op • Subacromial Impingement • Tear • Subacromial – Acute, Known • Adhesive Capsulitis – Chronic, Unknown Injury – “Frozen Shoulder” • Proximal Tear • Biceps Tendonitis • Labral Tear • Glenohumeral or AC Arthritis • AC Joint – “” • Shoulder Instability

Vanderbilt Sports Medicine Non-Arthritis Shoulder Pain

Non-Operative Operative &/or Non-Op • Subacromial Impingement • – Acute, Known Injury • Adhesive Capsulitis – Chronic, Unknown Injury – “Frozen Shoulder” • Proximal Biceps Tendon Tear • Biceps Tendonitis • Labral Tear • Glenohumeral or AC Joint Arthritis • AC Joint Sprain – “Separated Shoulder” • Shoulder Instability

Vanderbilt Sports Medicine Shoulder Pain Radiating Patterns •  Up SCM/Front of • Acromioclavicular Joint  Upper Trap/Lat. Neck • Subacromial Space  Lateral Brachium • Biceps  Anterior Brachium

Vanderbilt Sports Medicine Subacromial Impingement History Exam • Pain radiates from superolateral • Scapular dyskinesis on forward shoulder to lateral brachium elevation (FE) • Pain with reaching • Limited passive internal rotation (IR) • No rest pain • PROM ≥ AROM – Different than sleep/night pain… • Tender To at this will hurt • Pain AND on Empty-Can – Rest = Sitting with in testing at 90 ABduction in scapular • Usually insidious onset plane but NL at 30 and other Rot. • May be capped by an event or start Cuff/Shoulder/ muscle strength NL some time after an event • Pain AND Weakness resolve/improve • Primary or Secondary disorder with scapular retraction test • No change in shoulder pain with • Pain with Neer’s and Hawkins’ tests Neck ROM Vanderbilt Sports Medicine Scapular Dyskinesis

http://www.youtube.com/watch?v=ROsiiDsjm2o Vanderbilt Sports Medicine Empty-Can Test

Vanderbilt Sports Medicine http://www.mhhe.com/hper/physed/athletictraining/illustrations/ch22/22-16a.jpg Scapular Retraction Test

Vanderbilt Sports Medicine Kibler WB. Br J Sports Med 2010 Neer’s and Hawkins’ Tests for Impingement

Vanderbilt Sports Medicine http://thepainsource.com Subacromial Impingement Imaging Treatment • 3-4 views of the Shoulder • Rehab – AP Int. & Ext. Rotation & – Strengthen Scapular Stabilizers Axillary +/- Scapular-Y view • Rhomboids, Middle , – Usually normal Serratus Anterior • Obtain these in setting of – Stretch Tight Posterior Capsule and injury and/or to screen for calcific rotator cuff • Subacromial CS Injection tendonopathy or – To improve tolerance for Rehab • Subacromial Decompression • Neck XR only if reproducible only if conservative Tx fails radicular signs/symptoms

Vanderbilt Sports Medicine Calcific Rotator Cuff Tendonopathy

Vanderbilt Sports Medicine http://www.orthopaedicsone.com/display/MSKMed/Calcific+tendonitis+of+the+shoulder Calcific Rotator Cuff Tendonopathy Treatment • U/S Guided Lavage & CS Injection; Debridement if too large or failed CSI

Vanderbilt Sports Medicine http://www.ultrasoundcases.info/files/Jpg/lbox_22380.jpg http://www.nguyenthienhung.com/2012_09_01_archive.html Subacromial Bursitis

physioworks.com.au Vanderbilt Sports Medicine Subacromial Bursitis History Exam • Pain radiates from superolateral • Scapular dyskinesis on fwd. elev. (FE) shoulder to lateral brachium • Limited passive internal rotation (IR) • Pain with reaching • PROM ≥ AROM but pain in all planes • (+) Rest pain of motion – Different than sleep/night pain… • Tender To Palpation deep to this will hurt – Rest = Sitting with hands in lap • Pain AND weakness in all planes but • Usually rapid/sudden onset esp. on Empty-Can testing; Biceps – 10/10 Pain out of “Clear Blue Sky” and usually NL • May start soon after an event or • Symptoms may improve with recent incr. in activity scapular retraction test • No change in shoulder pain with • Pain with Neer’s and Hawkins’ tests Neck ROM

Vanderbilt Sports Medicine Subacromial Bursitis Imaging Treatment • 3-4 views of the Shoulder • Subacromial CS Injection – AP Int. & Ext. Rotation & • PO NSAIDs +/- Narcotics Axillary +/- Scapular-Y view – Ketorolac (Toradol) – Usually normal • Rehab after pain improvement • Obtain these in setting of to address Impingement injury and/or to screen for • Subacromial Decompression calcific rotator cuff +/- Bursectomy only if tendonopathy or conservative Tx fails osteoarthritis • Neck XR only if reproducible radicular signs/symptoms

Vanderbilt Sports Medicine Adhesive Capsulitis

http://physioworks.com.au/images/Injuries-Conditions/Frozen_Shoulder_Adhesive_Capsulitis.jpg Vanderbilt Sports Medicine Adhesive Capsulitis History Exam • (+) Rest Pain • Limited passive IR > ER > Abd > FE – Rest = Sitting with hands in lap • PROM = AROM • Pain worse with reaching • Diffusely Tender To Palpation • Progressive Loss of Motion • Pain in all planes of motion may limit – IR  ER & Abd  FE strength – Motion returns in opposite sequence • Limited motion can prohibit Neer’s • Most common in Females, 40-60 y/o and Hawkins’ tests • May have autoimmune or chronic inflammatory etiology – (25%), Hypothyroidism, IBD • Usually insidious onset • May be capped by event or the start some time after an event/trauma

• No change in pain w/ Neck ROM Vanderbilt Sports Medicine Adhesive Capsulitis

• Education & Expectations • Average of 9-18 months to run its course – Stage 1 – Freezing • Pain at rest AND progressive loss of motion – Internal Rotation  External Rotation and Abduction  Forward Elevation – Motion returns in opposite sequence – Stage 2 – Frozen • Rest pain resolves but severely limited motion and pain with reaching – Stage 3 – Thawing • ROM returns (IR last) and Impingement symptoms predominate – Stage 4 – Shoulder function is back to normal Vanderbilt Sports Medicine Adhesive Capsulitis Imaging Treatment • 3-4 views of the Shoulder • Education and Expectations – AP Int. & Ext. Rotation & Axillary • Glenohumeral CS Injection +/- Scapular-Y view – Level I – Superior to PO with fewer • Axillary view most difficult due to systemic effects; Repeat every 4-6 loss of motion weeks in Stage 1 and early Stage 2 – Usually normal Lorbach O et al. J Shldr Elb Sg. 2010 • Narcotics, Sleep Aids, NSAIDs • Rehab only AFTER Rest Pain resolves • Viscosupplementation – Level I – Not Clinically Significant Callis M. Rheumatol Int. 2006 • Manipulation Under Anesthesia if conservative Tx fails

Vanderbilt Sports Medicine Rotator Cuff Tear

orthop.washington.edu

Vanderbilt Sports Medicine http://stemcelldoc.files.wordpress.com/2009/01/mri-of-torn-rotater-cuff1.jpg Rotator Cuff Tear History Exam • Fall on outstretched arm • Limited AROM 2/2 weakness > – Abduction in scapular plane = pain but NL PROM Supraspinatus +/- Infraspinatus • Supraspinatus (70% of RCT) – External Rotation = Subscapularis – Weak Empty Can at 30 & Drop • c/o weakness > pain Arm test • Acute • Infraspinatus (20% of RCT) – Event after which c/o pain and – Weak ER & ER Lag Sign weakness and disability • Subscapularis (<1% of RCT) – ≤ 2-3 months – Weak IR & Belly Press or Lift Off • Chronic tests – Process/Gradual onset of weakness and pain – Event >3 months ago Vanderbilt Sports Medicine Drop Arm Test

http://www.youtube.com/watch?v=qvwYEoeHPaA Vanderbilt Sports Medicine Lag Sign and Belly Press Tests • Infraspinatus/Teres Min. Tear • Subscapularis Tear

Vanderbilt Sports Medicine http://www.psychiatrictimes.com/sites/default/files/rm/1628757.png http://www.psychiatrictimes.com/sites/default/files/rm/1628765.png Rotator Cuff Tear Imaging Treatment • 3-4 views of the Shoulder • Acute Tear = RCT Repair – AP Int. & Ext. Rotation & • Chronic Tear = Rehab Axillary +/- Scapular-Y view – Level II – 75% Return to NL Function – Usually normal & No Pain without Surgery at 2 yrs. – May show high riding humeral Kuhn JE. J Shoulder Surg. 2013 head above center of glenoid – Subacromial CS Injection for Pain • Loss of supraspinatus cap • Viscosupplementation • MRI if Acute RCT – Level I – Not Clinically Significant Chou WY. J Shoulder Elbow Surg. 2010 Meloni F. Eur J Radiol. 2008

Vanderbilt Sports Medicine Biceps Tendonopathy

Vanderbilt Sports Medicine http://chiropracticdubai.files.wordpress.com/2012/06/bicep-tendonitis-image1.jpg Biceps Tendonopathy History Exam • Pain radiates from anterior • Tender To Palpation overlying shoulder to anterior brachium proximal biceps tendon at bicepital • Pain with biceps flexion, especially groove with supinated • Pain with extension of the shoulder • Usually insidious sudden onset • Pain with resisted supination of wrist • May start soon after an event or and resisted biceps flexion recent incr. in activity • Pain with Speed’s (resisted shoulder • Often accompanies Impingement flexion with wrist supinated and • No change in shoulder pain with elbow extended) and Yergason’s Neck ROM (resisted wrist supination with elbow at 60-90°) tests

Vanderbilt Sports Medicine Speeds’ and Yergason’s Tests

http://www.mhhe.com/hper/physed/athletictraining/illustrations/ch22/22-17b.jpg Vanderbilt Sports Medicine http://www.studyblue.com/notes/note/n/upper-extremity-physical-exam/deck/6425897 Biceps Tendonopathy Imaging Treatment • 3-4 views of the Shoulder • Rehab – AP Int. & Ext. Rotation & – Eccentric Biceps Axillary +/- Scapular-Y view – Stretch Biceps in extension – Usually normal • Tendon Sheath CS Injection • Consider MSK U/S • Topical or PO NSAIDs or APAP – Usually used to confirm if Dx is unclear on exam or if using U/S • Ionto/Phonophoresis for guided CS injection • Biceps Tenodesis if conservative Tx fails

Vanderbilt Sports Medicine Interim Summary • Was there an injury/event? Or was it a process? – Injury/Event – Rot. Cuff Tear, Subacromial Bursitis, AC or GH Dislocation – Process – Impingement, Frozen Shoulder, Biceps Tendonitis, DJD • Do they have “Rest Pain”? – No – Impingement, Rotator Cuff Tear (after initiating pain), Prox. Biceps Tear – Yes – Subacromial Bursitis (rapid), Frozen Shoulder (gradual), DJD (constant), AC or GH Dislocation (acute) • Where does it hurt? Where does the pain go? What causes it? – AC-Lateral Neck, Subacromial Space-Lateral Brachium, Biceps-Ant. Brachium – Tendonopathy hurts with palpation, stretch, and contraction • Appropriate XR will adequately address most shoulder pain – Always include an A/P Int./Ext. Rotation views with an Axillary view – If Acute Rotator Cuff Tear suspected  MRI – If Glenohumeral Instability  Scapular-Y Vanderbilt Sports Medicine Questions or Comments

Vanderbilt Sports Medicine www.vanderbiltsportsmedicine.com

Thank You

Vanderbilt Sports Medicine Non-Arthritis Shoulder Pain

Non-Operative Operative &/or Non-Op • Subacromial Impingement • Rotator Cuff Tear • Subacromial Bursitis – Acute, Known Injury – Surgery • Adhesive Capsulitis – Chronic, Unknown Injury – Non-Op – “Frozen Shoulder” • Proximal Biceps Tendon Tear • Biceps Tendonitis • Labral Tear • Glenohumeral or AC Joint Arthritis • AC Joint Sprain – “Separated Shoulder” • Shoulder Instability

Vanderbilt Sports Medicine Proximal Biceps Tendon Tear Proximal Distal

www.eastbaysportsmed.com http://images.ookaboo.com/photo/m/Bicepstendon10_m.jpg

Vanderbilt Sports Medicine images..org Proximal Biceps Tendon Tear History Exam • Pain and/or pop at anterior • “Popeye Deformity” with defect shoulder but usually not painful proximal and bulge distal after initial event • ROM usually normal • May have bruising at anterior • May be Tender To Palpation at site of shoulder that tracks distally tear • Weakness on elbow flexion with in supinated position • Usually normal strength with hand at neutral or pronated

Vanderbilt Sports Medicine Proximal Biceps Tendon Tear Imaging Treatment • None required unless history • Reassurance of trauma • Surgery if – If trauma, XR to r/o fracture – Relative strength deficit is – MRI usually does not change intolerable or affects work/play management – Deformity is cosmetically unacceptable

Vanderbilt Sports Medicine Inflammatory Arthritides

Posttraumatic Osteoarthritis Arthritis

Shoulder Capsulorraphy Rotator Cuff Arthritis Arthropathy

Neuropathic Osteonecrosis Arthritis

Infection

Vanderbilt Sports Medicine Glenohumeral DJD History Exam • Pain deep in the shoulder • Limited P/AROM on IR/ER > FE that is constant; worse with • PROM = AROM reaching • Often have scapular dyskinesis – “Hopeless” pain • Usually NL Strength but may • (+) Rest Pain have Pain AND weakness on – Different than sleep/night  pain… this will hurt Empty-Can testing at 90 – Rest = Sitting with hands in lap ABduction in scapular plane – May be weak w/ Rot. Cuff • Usually insidious onset Arthropathy • No change in shoulder pain • Pain AND Weakness may with Neck ROM resolve/improve with scapular

retraction Vanderbilt Sports Medicine Glenohumeral DJD Imaging • 3-4 views of the Shoulder – AP Int. & Ext. Rotation & Axillary +/- Scapular-Y view – Joint space narrowing, , and humeral head and/or glenoid flattening

Vanderbilt Sports Medicine Glenohumeral DJD Treatment Non-Operative Operative • • Non- • Pain Medicine • Partial Joint Replacement – NSAIDs • Total Joint Replacement – Tylenol (APAP) • Reverse Total Joint Replacement – Narcotics • Steroid Injections • Viscosupplementation – Level I – Not Clinically Significant Blaine T et al. JBJS Am 2008 – Level II – Helps with Rotator Cuff Arthropathy Tagliafico A. Eur Radiol. 2011

Vanderbilt Sports Medicine Glenohumeral DJD Treatment Non-Operative Operative • Physical Therapy • Non-Joint Replacement • Pain Medicine • Partial Joint Replacement – NSAIDs • Total Joint Replacement – Tylenol (APAP) • Reverse Total Joint Replacement – Narcotics • Steroid Injections • Viscosupplementation – Level I – Not Clinically Significant Blaine T et al. JBJS Am 2008 – Level II – Helps with Rotator Cuff Arthropathy Tagliafico A. Eur Radiol. 2011

Vanderbilt Sports Medicine Glenohumeral DJD Treatment Non-Operative Operative • Physical Therapy • Non-Joint Replacement • Pain Medicine • Partial Joint Replacement – NSAIDs • Total Joint Replacement – Tylenol (APAP) • Reverse Total Joint Replacement – Narcotics • Steroid Injections • Viscosupplementation – Level I – Not Clinically Significant Blaine T et al. JBJS Am 2008 – Level II – Helps with Rotator Cuff Arthropathy Tagliafico A. Eur Radiol. 2011

Vanderbilt Sports Medicine Glenohumeral DJD Treatment Non-Operative Operative • Physical Therapy • Non-Joint Replacement • Pain Medicine • Partial Joint Replacement – NSAIDs • Total Joint Replacement – Tylenol (APAP) • Reverse Total Joint Replacement – Narcotics • Steroid Injections • Viscosupplementation – Level I – Not Clinically Significant Blaine T et al. JBJS Am 2008 – Level II – Helps with Rotator Cuff Arthropathy Tagliafico A. Eur Radiol. 2011

Vanderbilt Sports Medicine AC Joint DJD

www.shouldersurgery.com.au Vanderbilt Sports Medicine AC Joint DJD History Exam • Pain radiates from superior • Tender To Palpation at AC joint shoulder to lateral neck and upper • Pain with Cross-Arm Adduction test trapezius • Likely will have secondary • Pain with reaching, especially Impingement signs across – Scapular dyskinesis • Pain with pushups, , – Limited passive internal rotation (IR) and overhead lifting – Symptoms resolve/improve with scapular retraction test • Aching rest pain – Pain with Neer’s and Hawkins’ tests • Usually insidious onset • No change in shoulder pain with Neck ROM

Vanderbilt Sports Medicine Cross-Arm Adduction Test

http://i3.ytimg.com/vi/fV97PJxXJQg/default.jpg http://www.massagetherapy.com/ce/content/images/664.jpg

Vanderbilt Sports Medicine AC Joint DJD Imaging Treatment • 3-4 views of the Shoulder • AC joint CS Injection – AP Int. & Ext. Rotation & • Topical or PO NSAIDs and Ice Axillary +/- Scapular-Y view • Rehab – Joint space narrowing and osteophytes – Addressing Impingement mechanics off loads the AC joint • Neck XR only if reproducible • Strengthen Scapular Stabilizers radicular signs/symptoms • Stretch Tight Posterior Capsule and Pectoralis Minor • Distal Excision if conservative Tx fails

Vanderbilt Sports Medicine AC Joint Sprain

Vanderbilt Sports Medicine AC Joint Sprain History Exam • Fall onto/Blow to superolateral • Tender To Palpation at AC joint shoulder with ADducted arm • May have step off at AC Joint • Pain radiates from superior • Pain with Cross-Arm Adduction test shoulder to lateral neck and upper • Likely won’t have secondary trapezius Impingement signs unless they • Pain with reaching, especially present late across body • Pain can prohibit pushups, bench press, and overhead lifting • Aching rest pain • No change in shoulder pain with Neck ROM

Vanderbilt Sports Medicine AC Joint Sprain Imaging Treatment • 3-4 views of the Shoulder • Type I and II – Non-Op – AP Int. & Ext. Rotation & Axillary – Sling initially and Ice +/- Scapular-Y view – PO NSAIDs or APAP or Narcs (rare) – Degree of Separation determines – AC joint CS Injection type of dislocation – Rehab • Avoid developing Impingement • Type III – Non-Op or Surgery – If distal clavicle overrides acromion on Cross Arm ADduction test  Surgery • Type IV-VI - Surgery – AC Joint Reconstruction

Vanderbilt Sports Medicine www.aafp.org AC Joint Sprain XR

Grade 2 Grade 3

Vanderbilt Sports Medicine Grade 4 Grade 5 Glenohumeral Instability

http://www.imageinterpretation.co.uk/shoulder.html http://emcow.files.wordpress.com/2012/09/shoulder-disloc1.jpg Vanderbilt Sports Medicine http://www.intechopen.com/source/html/40393/media/image6_w.jpg Glenohumeral Instability History Exam • • Arm hanging at side – Popped back in w/o specific Tx • Inability to reach across body • Dislocation • Inability to externally rotate – Someone else reduces or specific arm technique used to relocate joint • Direction of Instability • Anterior Instability follows humeral head – Apprehension/Relocation tests • Sensitive & Specific for Fear, Not – ABduction-ER = Anterior (90%) Pain – Abduction = Inferior • Inferior Instability – Forward Elevation = Posterior – Sulcus on Traction tests • Posterior Instability – Posterior Jerk test Vanderbilt Sports Medicine Anterior Instability Apprehension and Relocation Tests

http://www.chiro.org/LINKS/FULL/Shoulder_Dislocation_in_Young_Athletes.html Vanderbilt Sports Medicine Posterior & Inferior Instability

Posterior Jerk Test Sulcus Sign with Traction Test

http://i1.ytimg.com/vi/gPuCikFKUzE/maxresdefault.jpg http://o.quizlet.com/Y8H2wK5Imz4g0bpp.9v3Pw_m.jpg Vanderbilt Sports Medicine Glenohumeral Instability Imaging Treatment • 4 views of the Shoulder • Reduce Dislocated Joint – AP Int. & Ext. Rotation & – Level I – Intra-articular lidocaine is Axillary & Scapular-Y view preferred to IV sedation • Axillary view prevents missing • Same success; Less complications (0.9 a posterior dislocation vs. 16.4%) Fitch RW, Kuhn JE. Acad Emerg Med 2008 • Classification • Sling Immobilization – Level I & II – Ext. Rot. may reduce recurrence; Req. 3 wks. (1/4 studies) Itoi et al. JBJS 2007 • Sling vs. Surgery (No studies Rehab vs. Sx) – Level I – Non-Op Tx has higher risk of recurrence (47 vs. 16%) Kirkley et al. 1999 Vanderbilt Sports Medicine Kuhn JE, Dunn WR et al. J Shoulder Elbow Surg. 2011 Final Summary • Was there an injury/event? Or was it a process? – Injury/Event – Rot. Cuff Tear, Subacromial Bursitis, AC or GH Dislocation – Process – Impingement, Frozen Shoulder, Biceps Tendonitis, DJD • Do they have “Rest Pain”? – No – Impingement, Rotator Cuff Tear (after initiating pain), Prox. Biceps Tear – Yes – Subacromial Bursitis (rapid), Frozen Shoulder (gradual), DJD (constant), AC or GH Dislocation (acute) • Where does it hurt? Where does the pain go? What causes it? – AC-Lateral Neck, Subacromial Space-Lateral Brachium, Biceps-Ant. Brachium – Tendonopathy hurts with palpation, stretch, and contraction • Appropriate XR will adequately address most shoulder pain – Always include an A/P Int./Ext. Rotation views with an Axillary view – If Acute Rotator Cuff Tear suspected  MRI – If Glenohumeral Instability  Scapular-Y Vanderbilt Sports Medicine Questions or Comments

Vanderbilt Sports Medicine www.vanderbiltsportsmedicine.com

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Vanderbilt Sports Medicine